Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
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Evaluation of the Laboratory Response Network and testing access during the first 10 weeks of the mpox response, United States, May 17-July 31, 2022
Thomas KL , Aden TA , Blevins PA , Raziano AJ , Wolford T , Honein MA , Villanueva JM . Public Health Rep 2024 333549241269497 ![]() ![]() OBJECTIVES: The Laboratory Response Network (LRN) consists of US and international laboratories that respond to public health emergencies, such as biothreats. We used a qualitative approach to assess the successes and challenges of the LRN during the initial 10 weeks of the 2022 mpox outbreak (May 17-July 31, 2022). METHODS: We conducted 9 unstructured interviews, which included 3 interviews with subject matter experts from the Centers for Disease Control and Prevention (CDC) and 6 interviews with state and local public health laboratories and epidemiologists and Association of Public Health Laboratories (APHL) staff. We asked guiding questions on investments in preparedness, successes, and challenges during the initial mpox response and asked for suggestions to improve future LRN responses to infectious disease outbreaks. We also reviewed data from 2 contemporaneous APHL surveys conducted in June and July 2022 in 84 LRN public health laboratories. RESULTS: Notable successes included availability of an assay that had received clearance from the US Food and Drug Administration (FDA) for testing orthopoxviruses (non-variola Orthopoxvirus [NVO] assay) and a trained workforce; strong relationships among FDA, CDC, and the LRN; and strong communications between LRN laboratories and CDC. Challenges included variability among LRN laboratories in self-reported testing capacity, barriers to accessing the NVO assay for health care providers, and gaps in LRN function during surges of testing needs. CONCLUSIONS: The LRN system plays an essential role in the response to emerging infectious disease outbreaks in the United States. Lessons learned from the LRN's initial response to the mpox outbreak can help guide improvements to better position the LRN for future responses, including continued engagement with health care providers, commercial laboratories, and laboratories in health care settings. |
Length of antibiotic therapy among adults hospitalized with uncomplicated community-acquired pneumonia, 2013-2020
McCarthy NL , Baggs J , Wolford H , Kazakova SV , Kabbani S , Attell BK , Neuhauser MM , Walker L , Yi SH , Hatfield KM , Reddy S , Hicks LA . Infect Control Hosp Epidemiol 2024 1-7 OBJECTIVE: The 2014 US National Strategy for Combating Antibiotic-Resistant Bacteria (CARB) aimed to reduce inappropriate inpatient antibiotic use by 20% for monitored conditions, such as community-acquired pneumonia (CAP), by 2020. We evaluated annual trends in length of therapy (LOT) in adults hospitalized with uncomplicated CAP from 2013 through 2020. METHODS: We conducted a retrospective cohort study among adults with a primary diagnosis of bacterial or unspecified pneumonia using International Classification of Diseases Ninth and Tenth Revision codes in MarketScan and the Centers for Medicare & Medicaid Services databases. We included patients with length of stay (LOS) of 2-10 days, discharged home with self-care, and not rehospitalized in the 3 days following discharge. We estimated inpatient LOT based on LOS from the PINC AI Healthcare Database. The total LOT was calculated by summing estimated inpatient LOT and actual postdischarge LOT. We examined trends from 2013 to 2020 in patients with total LOT >7 days, which was considered an indicator of likely excessive LOT. RESULTS: There were 44,976 and 400,928 uncomplicated CAP hospitalizations among patients aged 18-64 years and ≥65 years, respectively. From 2013 to 2020, the proportion of patients with total LOT >7 days decreased by 25% (68% to 51%) among patients aged 18-64 years and by 27% (68%-50%) among patients aged ≥65 years. CONCLUSIONS: Although likely excessive LOT for uncomplicated CAP patients decreased since 2013, the proportion of patients treated with LOT >7 days still exceeded 50% in 2020. Antibiotic stewardship programs should continue to pursue interventions to reduce likely excessive LOT for common infections. |
Antibiotic use among hospitalized patients with COVID-19 in the United States, March 2020-June 2022
Kim C , Wolford H , Baggs J , Reddy S , Hicks LA , Neuhauser MM , Kabbani S . Open Forum Infect Dis 2023 10 (11) ofad503 We conducted a retrospective study to describe antibiotic use among US adults hospitalized with a COVID-19 diagnosis. Despite a decrease in overall antibiotic use, most patients hospitalized with COVID-19 received antibiotics on admission (88.1%) regardless of critical care status, highlighting that more efforts are needed to optimize antibiotic therapy. |
Reducing travel-related SARS-CoV-2 transmission with layered mitigation measures: Symptom monitoring, quarantine, and testing (preprint)
Johansson MA , Wolford H , Paul P , Diaz PS , Chen TH , Brown CM , Cetron MS , Alvarado-Ramy F . medRxiv 2020 2020.11.23.20237412 Balancing the control of SARS-CoV-2 transmission with the resumption of travel is a global priority. Current recommendations include mitigation measures before, during, and after travel. Pre- and post-travel strategies including symptom monitoring, testing, and quarantine can be combined in multiple ways considering different trade-offs in feasibility, adherence, effectiveness, cost and adverse consequences. Here we use a mathematical model to analyze the expected effectiveness of symptom monitoring, testing, and quarantine under different estimates of the infectious period, test-positivity relative to time of infection, and test sensitivity to reduce the risk of transmission from infected travelers during and after travel. If infection occurs 0-7 days prior to travel, immediate isolation following symptom onset prior to or during travel reduces risk of transmission while traveling by 26-30%. Pre-departure testing can further reduce risk if testing is close to the time of departure. For example, testing on the day of departure can reduce risk while traveling by 37-61%. For transmission risk after travel with infection time up to 7 days prior to arrival at the destination, isolation based on symptom monitoring reduced introduction risk at the destination by 42-56%. A 14-day quarantine after arrival, without symptom monitoring or testing, can reduce risk by 97-100% on its own. However, a shorter quarantine of 7 days combined with symptom monitoring and a test on day 3-4 after arrival is also effective (95-99%) at reducing introduction risk and is less burdensome, which may improve adherence. To reduce the risk of introduction without quarantine, optimal test timing after arrival is close to the time of arrival; with effective quarantine after arrival, testing a few days later optimizes sensitivity to detect those infected immediately before or while traveling. These measures can complement recommendations such as social distancing, using masks, and hand hygiene, to further reduce risk during and after travel.Competing Interest StatementThe authors have declared no competing interest.Funding StatementNo external funding supported this research.Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:Centers for Disease Control and PreventionAll necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesOnly publicly available data informed this research. |
Distinct origins and transmission pathways of bla(KPC) enterobacterales across three U.S. States
Lapp Z , Octaria R , O'Malley SM , Nguyen TN , Wolford H , Crawford R , Moore C , Snippes Vagnone P , Noel D , Duffy N , Pirani A , Thomas LS , Pattee B , Pearson C , Bulens SN , Hoffman S , Kainer M , Anacker M , Meek J , See I , Gontjes KJ , Chan A , Lynfield R , Maloney M , Hayden MK , Snitkin E , Slayton RB . J Clin Microbiol 2023 61 (8) e0025923 ![]() ![]() Carbapenem-resistant Enterobacterales (CRE) are among the most concerning antibiotic resistance threats due to high rates of multidrug resistance, transmissibility in health care settings, and high mortality rates. We evaluated the potential for regional genomic surveillance to track the spread of bla(KPC)-carrying CRE (KPC-CRE) by using isolate collections from health care facilities in three U.S. states. Clinical isolates were collected from Connecticut (2017 to 2018), Minnesota (2012 to 2018), and Tennessee (2016 to 2017) through the U.S. Centers for Disease Control and Prevention's Multi-site Gram-negative Surveillance Initiative (MuGSI) and additional surveillance. KPC-CRE isolates were whole-genome sequenced, yielding 255 isolates from 214 patients across 96 facilities. Case report data on patient comorbidities, facility exposures, and interfacility patient transfer were extracted. We observed that in Connecticut, most KPC-CRE isolates showed evidence of importation from outside the state, with limited local transmission. In Minnesota, cases were mainly from sporadic importation and transmission of bla(KPC)-carrying Klebsiella pneumoniae ST258, and clonal expansion of bla(KPC)-carrying Enterobacter hormaechei ST171, primarily at a single focal facility and its satellite facilities. In Tennessee, we observed transmission of diverse strains of bla(KPC)-carrying Enterobacter and Klesbiella, with evidence that most derived from the local acquisition of bla(KPC) plasmids circulating in an interconnected regional health care network. Thus, the underlying processes driving KPC-CRE burden can differ substantially across regions and can be discerned through regional genomic surveillance. This study provides proof of concept that integrating genomic data with information on interfacility patient transfers can provide insights into locations and drivers of regional KPC-CRE burden that can enable targeted interventions. |
Hospitalizations for unspecified mycoses in a large administrative data set and implications for fungal disease burden estimates, United States, 2019-2021
Benedict K , Baggs J , Wolford H , Jackson BR , Gold JAW . Open Forum Infect Dis 2023 10 (3) ofad100 Fungal diseases are frequently coded as "unspecified mycoses" in data sets used to estimate disease burden. In a large administrative database, 50.9% of unspecified mycosis hospitalizations during 2019-2021 had positive fungal laboratory testing, most commonly Candida (79.1%), highlighting a potential need for improved coding practices and greater fungal laboratory testing. |
Declines in the utilization of hospital-based care during COVID-19 pandemic.
Kazakova SV , Baggs J , Parra G , Yusuf H , Romano SD , Ko JY , Harris AM , Wolford H , Rose A , Reddy SC , Jernigan JA . J Hosp Med 2022 17 (12) 984-989 The disruptions of the coronavirus disease 2019 (COVID-19) pandemic impacted the delivery and utilization of healthcare services with potential long-term implications for population health and the hospital workforce. Using electronic health record data from over 700 USacute care hospitals, we documented changes in admissions to hospital service areas (inpatient, observation, emergency room [ER], and same-day surgery) during 2019-2020 and examined whether surges of COVID-19 hospitalizations corresponded with increased inpatient disease severity and death rate. We found that in 2020, hospitalizations declined by 50% in April, with greatest declines occurring in same-day surgery (-73%). The youngest patients (0-17) experienced largest declines in ER, observation, and same-day surgery admissions; inpatient admissions declined the most among the oldest patients (65+). Infectious disease admissions increased by 52%. The monthly measures of inpatient case mix index, length of stay, and non-COVID death rate were higher in all months in 2020 compared with respective months in 2019. |
Effectiveness of COVID-19 vaccination against SARS-CoV-2 Infection among Residents of US Nursing Homes, Before and During the Delta variant Predominance, December 2020 - November 2021.
Hatfield KM , Baggs J , Wolford H , Fang M , Sattar AA , Montgomery KS , Jin S , Jernigan J , Pilishvili T . Clin Infect Dis 2022 75 S147-S154 ![]() BACKGROUND: Residents of nursing homes experience disproportionate morbidity and mortality related to COVID-19 and were prioritized for vaccine introduction. We evaluated COVID-19 vaccine effectiveness (VE) in preventing SARS-CoV-2 infections among nursing home residents. METHODS: We used a retrospective cohort of 4,315 nursing home residents during December 14, 2020 - November 9, 2021. A Cox proportional hazards model was used to estimate hazard ratios comparing residents with a completed vaccination series to unvaccinated among those with and without prior SARS-CoV-2 infection (identified using positive SARS-CoV-2 tests and/or diagnosis codes), by vaccine product, and by period (before and during Delta variant predominance). VE was estimated as one minus the hazard ratio times 100%. RESULTS: Overall adjusted VE for the completed vaccination series was 58% (95%CI: 44%, 69%) among residents without a history of SARS-CoV-2 infection. During the pre-Delta period, the VE within 150 days of receipt of the second dose of Pfizer-BioNTech (67%, 95%CI: 40%, 82%) and Moderna (75%, 95%CI: 32%, 91%) was similar. During the Delta period, VE measured >150 days after the second dose was 33% (95%CI: -2%, 56%) for Pfizer-BioNTech and 77% (95%CI: 48%, 91%) for Moderna. Rates of infection were 78% lower (95%CI: 67%, 85%) among residents with prior SARS-CoV-2 infection and completed vaccination series compared to unvaccinated residents without a history of SARS-CoV-2 infection. CONCLUSIONS: COVID-19 vaccines were effective in preventing SARS-CoV-2 infections among nursing home residents and history of prior SARS-CoV-2 infection provided additional protection. Maintaining high coverage of recommended doses of COVID-19 vaccines remains a critical tool for preventing infections in nursing homes. |
Rapid diagnostic testing for response to the monkeypox outbreak - Laboratory Response Network, United States, May 17-June 30, 2022
Aden TA , Blevins P , York SW , Rager S , Balachandran D , Hutson CL , Lowe D , Mangal CN , Wolford T , Matheny A , Davidson W , Wilkins K , Cook R , Roulo RM , White MK , Berman L , Murray J , Laurance J , Francis D , Green NM , Berumen RA3rd , Gonzalez A , Evans S , Hudziec M , Noel D , Adjei M , Hovan G , Lee P , Tate L , Gose RB , Voermans R , Crew J , Adam PR , Haydel D , Lukula S , Matluk N , Shah S , Featherston J , Ware D , Pettit D , McCutchen E , Acheampong E , Buttery E , Gorzalski A , Perry M , Fowler R , Lee RB , Nickla R , Huard R , Moore A , Jones K , Johnson R , Swaney E , Jaramillo J , Reinoso Webb C , Guin B , Yost J , Atkinson A , Griffin-Thomas L , Chenette J , Gant J , Sterkel A , Ghuman HK , Lute J , Smole SC , Arora V , Demontigny CK , Bielby M , Geeter E , Newman KAM , Glazier M , Lutkemeier W , Nelson M , Martinez R , Chaitram J , Honein MA , Villanueva JM . MMWR Morb Mortal Wkly Rep 2022 71 (28) 904-907 As part of public health preparedness for infectious disease threats, CDC collaborates with other U.S. public health officials to ensure that the Laboratory Response Network (LRN) has diagnostic tools to detect Orthopoxviruses, the genus that includes Variola virus, the causative agent of smallpox. LRN is a network of state and local public health, federal, U.S. Department of Defense (DOD), veterinary, food, and environmental testing laboratories. CDC developed, and the Food and Drug Administration (FDA) granted 510(k) clearance* for the Non-variola Orthopoxvirus Real-time PCR Primer and Probe Set (non-variola Orthopoxvirus [NVO] assay), a polymerase chain reaction (PCR) diagnostic test to detect NVO. On May 17, 2022, CDC was contacted by the Massachusetts Department of Public Health (DPH) regarding a suspected case of monkeypox, a disease caused by the Orthopoxvirus Monkeypox virus. Specimens were collected and tested by the Massachusetts DPH public health laboratory with LRN testing capability using the NVO assay. Nationwide, 68 LRN laboratories had capacity to test approximately 8,000 NVO tests per week during June. During May 17-June 30, LRN laboratories tested 2,009 specimens from suspected monkeypox cases. Among those, 730 (36.3%) specimens from 395 patients were positive for NVO. NVO-positive specimens from 159 persons were confirmed by CDC to be monkeypox; final characterization is pending for 236. Prompt identification of persons with infection allowed rapid response to the outbreak, including isolation and treatment of patients, administration of vaccines, and other public health action. To further facilitate access to testing and increase convenience for providers and patients by using existing provider-laboratory relationships, CDC and LRN are supporting five large commercial laboratories with a national footprint (Aegis Science, LabCorp, Mayo Clinic Laboratories, Quest Diagnostics, and Sonic Healthcare) to establish NVO testing capacity of 10,000 specimens per week per laboratory. On July 6, 2022, the first commercial laboratory began accepting specimens for NVO testing based on clinician orders. |
Antibiotic Resistant Infections among COVID-19 Inpatients in U.S. Hospitals.
Baggs J , Rose AN , McCarthy NL , Wolford H , Srinivasan A , Jernigan JA , Reddy SC . Clin Infect Dis 2022 75 S294-S297 We described bacterial/fungal co-infections and antibiotic resistant infections among inpatients diagnosed with COVID-19 and compared findings with inpatients diagnosed with influenza-like-illness. Less than 10% of COVID-19 inpatients had bacterial/fungal co-infection. Longer lengths of stay, critical care stay, and mechanical ventilation contribute to increased incidence of hospital-onset infections among COVID-19 inpatients. |
Trimethoprim-sulfamethoxazole resistance patterns among Staphylococcus aureus in the United States, 2012-2018
Ham DC , Fike L , Wolford H , Lastinger L , Soe M , Baggs J , Walters MS . Infect Control Hosp Epidemiol 2022 44 (5) 1-4 We reviewed trimethoprim-sulfamethoxazole antibiotic susceptibility testing data among Staphylococcus aureus using 3 national inpatient databases. In all 3 databases, we observed an increases in the percentage of methicillin-resistant Staphylococcus aureus that were not susceptible to trimethoprim-sulfamethoxazole. Providers should select antibiotic regimens based on local resistance patterns and should report changes to the public health department. |
Trends in Antibiotic Use in United States Hospitals During the Coronavirus Disease 2019 Pandemic.
Rose AN , Baggs J , Wolford H , Neuhauser MM , Srinivasan A , Gundlapalli AV , Reddy S , Kompaniyets L , Pennington AF , Grigg C , Kabbani S . Open Forum Infect Dis 2021 8 (6) ofab236 We described antibiotic use among inpatients with coronavirus disease 2019 (COVID-19). Most COVID-19 inpatients received antibiotic therapy. We also described hospital-wide antibiotic use during 2020 compared with 2019, stratified by hospital COVID-19 burden. Although total antibiotic use decreased between years, certain antibiotic use increased with higher COVID-19 burden. |
Cruise ship travel in the era of COVID-19: A summary of outbreaks and a model of public health interventions.
Guagliardo SAJ , Prasad PV , Rodriguez A , Fukunaga R , Novak RT , Ahart L , Reynolds J , Griffin I , Wiegand R , Quilter LAS , Morrison S , Jenkins K , Wall HK , Treffiletti A , White SB , Regan J , Tardivel K , Freeland A , Brown C , Wolford H , Johansson MA , Cetron MS , Slayton RB , Friedman CR . Clin Infect Dis 2021 74 (3) 490-497 BACKGROUND: Cruise travel contributed to SARS-CoV-2 transmission when there were relatively few cases in the United States. By March 14, 2020, the Centers for Disease Control and Prevention (CDC) issued a No Sail Order suspending U.S. cruise operations; the last U.S. passenger ship docked on April 16. METHODS: We analyzed SARS-CoV-2 outbreaks on cruises in U.S. waters or carrying U.S. citizens and used regression models to compare voyage characteristics. We used compartmental models to simulate the potential impact of four interventions (screening for COVID-19 symptoms; viral testing on two days and isolation of positive persons; reduction of passengers by 40%, crew by 20%, and port visits to one) for 7-day and 14-day voyages. RESULTS: During January 19-April 16, 2020, 89 voyages on 70 ships had known SARS-CoV-2 outbreaks; 16 ships had recurrent outbreaks. There were 1,669 RT-PCR-confirmed SARS-CoV-2 infections and 29 confirmed deaths. Longer voyages were associated with more cases (adjusted incidence rate ratio, 1.10, 95% CI: 1.03-1.17, p < 0.0001). Mathematical models showed that 7-day voyages had about 70% fewer cases than 14-day voyages. On 7-day voyages, the most effective interventions were reducing the number of individuals onboard (43-49% reduction in total infections) and testing passengers and crew (42-43% reduction in total infections). All four interventions reduced transmission by 80%, but no single intervention or combination eliminated transmission. Results were similar for 14-day voyages. CONCLUSIONS: SARS-CoV-2 outbreaks on cruises were common during January-April 2020. Despite all interventions modeled, cruise travel still poses a significant SARS-CoV-2 transmission risk. |
Reducing travel-related SARS-CoV-2 transmission with layered mitigation measures: symptom monitoring, quarantine, and testing.
Johansson MA , Wolford H , Paul P , Diaz PS , Chen TH , Brown CM , Cetron MS , Alvarado-Ramy F . BMC Med 2021 19 (1) 94 BACKGROUND: Balancing the control of SARS-CoV-2 transmission with the resumption of travel is a global priority. Current recommendations include mitigation measures before, during, and after travel. Pre- and post-travel strategies including symptom monitoring, antigen or nucleic acid amplification testing, and quarantine can be combined in multiple ways considering different trade-offs in feasibility, adherence, effectiveness, cost, and adverse consequences. METHODS: We used a mathematical model to analyze the expected effectiveness of symptom monitoring, testing, and quarantine under different estimates of the infectious period, test-positivity relative to time of infection, and test sensitivity to reduce the risk of transmission from infected travelers during and after travel. RESULTS: If infection occurs 0-7 days prior to travel, immediate isolation following symptom onset prior to or during travel reduces risk of transmission while traveling by 30-35%. Pre-departure testing can further reduce risk, with testing closer to the time of travel being optimal even if test sensitivity is lower than an earlier test. For example, testing on the day of departure can reduce risk while traveling by 44-72%. For transmission risk after travel with infection time up to 7 days prior to arrival at the destination, isolation based on symptom monitoring reduced introduction risk at the destination by 42-56%. A 14-day quarantine after arrival, without symptom monitoring or testing, can reduce post-travel risk by 96-100% on its own. However, a shorter quarantine of 7 days combined with symptom monitoring and a test on day 5-6 after arrival is also effective (97--100%) at reducing introduction risk and is less burdensome, which may improve adherence. CONCLUSIONS: Quarantine is an effective measure to reduce SARS-CoV-2 transmission risk from travelers and can be enhanced by the addition of symptom monitoring and testing. Optimal test timing depends on the effectiveness of quarantine: with low adherence or no quarantine, optimal test timing is close to the time of arrival; with effective quarantine, testing a few days later optimizes sensitivity to detect those infected immediately before or while traveling. These measures can complement recommendations such as social distancing, using masks, and hand hygiene, to further reduce risk during and after travel. |
National estimates of healthcare costs associated with multidrug-resistant bacterial infections among hospitalized patients in the United States
Nelson RE , Hatfield KM , Wolford H , Samore MH , Scott RD , Reddy SC , Olubajo B , Paul P , Jernigan JA , Baggs J . Clin Infect Dis 2021 72 S17-s26 BACKGROUND: Treating patients with infections due to multidrug-resistant pathogens often requires substantial healthcare resources. The purpose of this study was to report estimates of the healthcare costs associated with infections due to multidrug-resistant bacteria in the United States (US). METHODS: We performed retrospective cohort studies of patients admitted for inpatient stays in the Department of Veterans Affairs healthcare system between January 2007 and October 2015. We performed multivariable generalized linear models to estimate the attributable cost by comparing outcomes in patients with and without positive cultures for multidrug-resistant bacteria. Finally, we multiplied these pathogen-specific, per-infection attributable cost estimates by national counts of infections due to each pathogen from patients hospitalized in a cohort of 722 US hospitals from 2017 to generate estimates of the population-level healthcare costs in the US attributable to these infections. RESULTS: Our analysis cohort consisted of 16 676 patients with community-onset infections and 172 712 matched controls and 8246 patients with hospital-onset infections and 66 939 matched controls. The highest cost was seen in hospital-onset invasive infections, with attributable costs (95% confidence intervals) ranging from $30 998 ($25 272-$36 724) for methicillin-resistant Staphylococcus aureus to $74 306 ($20 377-$128 235) for carbapenem-resistant (CR) Acinetobacter. The highest attributable costs for community-onset invasive infections were seen in CR Acinetobacter ($62 396; $20 370-$104 422). Treatment of these infections cost an estimated $4.6 billion ($4.1 billion-$5.1 billion) in 2017 in the US for community- and hospital-onset infections combined. CONCLUSIONS: We found that antimicrobial-resistant infections led to substantial healthcare costs. |
Web-based interactive tool to identify facilities at risk of receiving patients with multidrug-resistant organisms
Octaria R , Chan A , Wolford H , Devasia R , Moon TD , Zhu Y , Slayton RB , Kainer MA . Emerg Infect Dis 2020 26 (9) 2046-2053 To identify facilities at risk of receiving patients colonized or infected with multidrug-resistant organisms (MDROs), we developed an interactive web-based interface for visualization of patient-sharing networks among healthcare facilities in Tennessee, USA. Using hospital discharge data and the Centers for Medicare and Medicaid Services' claims and Minimum Data Set, we constructed networks among hospitals and skilled nursing facilities. Networks included direct and indirect transfers, which accounted for <365 days in the community outside of facility admissions. Authorized users can visualize a facility of interest and tailor visualizations by year, network dataset, length of time in the community, and minimum number of transfers. The interface visualizes the facility of interest with its connected facilities that receive or send patients, the number of interfacility transfers, and facilities at risk of receiving transfers from the facility of interest. This tool will help other health departments enhance their MDRO outbreak responses. |
Multidrug-resistant bacterial infections in U.S. hospitalized patients, 2012-2017
Jernigan JA , Hatfield KM , Wolford H , Nelson RE , Olubajo B , Reddy SC , McCarthy N , Paul P , McDonald LC , Kallen A , Fiore A , Craig M , Baggs J . N Engl J Med 2020 382 (14) 1309-1319 BACKGROUND: Multidrug-resistant (MDR) bacteria that are commonly associated with health care cause a substantial health burden. Updated national estimates for this group of pathogens are needed to inform public health action. METHODS: Using data from patients hospitalized in a cohort of 890 U.S. hospitals during the period 2012-2017, we generated national case counts for both hospital-onset and community-onset infections caused by methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), extended-spectrum cephalosporin resistance in Enterobacteriaceae suggestive of extended-spectrum beta-lactamase (ESBL) production, carbapenem-resistant Enterobacteriaceae, carbapenem-resistant acinetobacter species, and MDR Pseudomonas aeruginosa. RESULTS: The hospital cohort in the study accounted for 41.6 million hospitalizations (>20% of U.S. hospitalizations annually). The overall rate of clinical cultures was 292 cultures per 1000 patient-days and was stable throughout the time period. In 2017, these pathogens caused an estimated 622,390 infections (95% confidence interval [CI], 579,125 to 665,655) among hospitalized patients. Of these infections, 517,818 (83%) had their onset in the community, and 104,572 (17%) had their onset in the hospital. MRSA and ESBL infections accounted for the majority of the infections (52% and 32%, respectively). Between 2012 and 2017, the incidence decreased for MRSA infection (from 114.18 to 93.68 cases per 10,000 hospitalizations), VRE infection (from 24.15 to 15.76 per 10,000), carbapenem-resistant acinetobacter species infection (from 3.33 to 2.47 per 10,000), and MDR P. aeruginosa infection (from 13.10 to 9.43 per 10,000), with decreases ranging from -20.5% to -39.2%. The incidence of carbapenem-resistant Enterobacteriaceae infection did not change significantly (from 3.36 to 3.79 cases per 10,000 hospitalizations). The incidence of ESBL infection increased by 53.3% (from 37.55 to 57.12 cases per 10,000 hospitalizations), a change driven by an increase in community-onset cases. CONCLUSIONS: Health care-associated antimicrobial resistance places a substantial burden on patients in the United States. Further work is needed to identify improved interventions for both the inpatient and outpatient settings. (Funded by the Centers for Disease Control and Prevention.). |
Whole Genome Sequencing to Identify Drivers of Carbapenem-Resistant Klebsiella pneumoniae Transmission Within and Between Regional Long-Term Acute Care Hospitals.
Han JH , Lapp Z , Bushman F , Lautenbach E , Goldstein EJC , Mattei L , Hofstaedter CE , Kim D , Nachamkin I , Garrigan C , Jain T , Bilker W , Wolford HM , Slayton RB , Wise J , Tolomeo P , Snitkin ES . Antimicrob Agents Chemother 2019 63 (11) ![]() ![]() Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an antibiotic resistance threat of the highest priority. Given the limited treatment options for this multidrug-resistant organism (MDRO), there is an urgent need for targeted strategies to prevent transmission. Here, we applied whole-genome sequencing to a comprehensive collection of clinical isolates to reconstruct regional transmission pathways, and analyzed this transmission network in the context of statewide patient transfer data and patient-level clinical data to identify drivers of regional transmission. We found that high regional CRKP burden was due to a small number of regional introductions, with subsequent regional proliferation occurring via patient transfers among healthcare facilities. While CRKP was predicted to be imported into each facility multiple times, there was substantial variation in the ratio of intra-facility transmission events per importation, indicating that amplification occurs unevenly across regional facilities. While myriad factors likely influence intra-facility transmission rates, an understudied one is the potential for clinical characteristics of colonized and infected patient to influence their propensity for transmission. Supporting the contribution of high-risk patients to elevated transmission rates, we observed that CRKP colonized and infected patients in high transmission facilities had higher rates of carbapenem use, malnutrition, old age and dialysis. This study highlights the potential for regional infection prevention efforts that are grounded in genomic epidemiology to identify patients and facilities that make the greatest contribution to regional MDRO prevalence, thereby facilitating the design of precision interventions of maximal impact. |
Evaluating movement of patients with Carbapenem-Resistant Enterobacteriaceae infections in the Greater Atlanta Metropolitan Area using social network analysis
Bower CW , Fridkin DW , Wolford HM , Slayton RB , Kubes JN , Jacob JT , Ray SM , Fridkin SK . Clin Infect Dis 2019 70 (1) 75-81 BACKGROUND: Carbapenem-resistant Enterobacteriaceae (CRE) are an urgent threat with potential for rapid spread. We evaluated the role of Medicare patient movement between facilities to model the spread of CRE within a region. METHODS: Through population-based CRE surveillance in the 8-county Atlanta Metropolitan area (population 4.1 million), all Escherichiacoli, Enterobacter spp, or Klebsiella spp. resistant to >/=1 carbapenem collected from urine or a normally sterile site were reported from residents. CRE was attributed to a facility based on timing of culture and facility exposures in the previous year; centrality metrics were calculated from 2016 Medicare data and compared to CRE-transfer derived centrality metrics by Spearman correlation. RESULTS: During 2016, 283 incident CRE cases with concurrent or prior year facility stays were identified; cases were attributed mostly to acute care hospitals (ACH: 141, 50%) and skilled nursing facilities (SNF: 113, 40%), and less frequently to long term acute care hospitals (LTACH: 29, 10%). Attribution was widespread, originating at 17 of 20 ACH (85%), 7 of 8 (88%) LTACH, but only 35 of 65 (54%) SNFs. Betweenness of Medicare patient-transfers strongly correlated with betweenness of CRE case-transfer data in ACHs (r=0.75; P<.01) and LTACHs (r=0.77; P=.03), but not in SNFs (r=0.02; p=0.85). We note six SNFs with high CRE-derived betweenness but low Medicare-derived betweenness. CONCLUSION: CRE infections originate from almost all ACHs and about half of SNFs. We identified a subset of SNFs very central to the CRE transfer network but not the Medicare transfer network; other factors may better explain CRE patient movement in these facilities. |
The projected burden of complex surgical site infections following hip and knee arthroplasties in adults in the United States, 2020 through 2030
Wolford HM , Hatfield KM , Paul P , Yi SH , Slayton RB . Infect Control Hosp Epidemiol 2018 39 (10) 1-7 BACKGROUND: As the US population ages, the number of hip and knee arthroplasties is expected to increase. Because surgical site infections (SSIs) following these procedures contribute substantial morbidity, mortality, and costs, we projected SSIs expected to occur from 2020 through 2030. METHODS: We used a stochastic Poisson process to project the number of primary and revision arthroplasties and SSIs. Primary arthroplasty rates were calculated using annual estimates of hip and knee arthroplasty stratified by age and gender from the 2012-2014 Nationwide Inpatient Sample and standardized by census population data. Revision rates, dependent on time from primary procedure, were obtained from published literature and were uniformly applied for all ages and genders. Stratified complex SSI rates for arthroplasties were obtained from 2012-2015 National Healthcare Safety Network data. To evaluate the possible impact of prevention measures, we recalculated the projections with an SSI rate reduced by 30%, the national target established by the US Department of Health and Human Services (HHS). RESULTS: Without a reduction in SSI rates, we projected an increase in complex SSIs following hip and knee arthroplasty of 14% between 2020 and 2030. We projected a total burden of 77,653 SSIs; however, meeting the 30% rate reduction could prevent 23,297 of these SSIs. CONCLUSIONS: Given current SSI rates, we project that complex SSI burden for primary and revision arthroplasty may increase due to an aging population. Reducing the SSI rate to the national HHS target could prevent 23,000 SSIs and reduce subsequent morbidity, mortality, and Medicare costs. |
Record matching between the National Hospital Care Survey and the National Death Index
Levant S , Wolford M . Proc Am Stat Assoc 2015 0 1-16 Linking the National Hospital Care Survey (NHCS) with the National Death Index (NDI) provides information on the outcomes of hospitalizations and allows for analysis of individual and provider characteristics associated with in-hospital and post-discharge mortality. We test the viability of confirming hospital mortality through the linkage of preliminary 2011 NHCS data for "known dead" inpatient discharges (i.e., patients that died during a hospitalization) with the NDI, assessing the true match rate and the quality of the match. We then expand the analysis to identify patients with a 30-, 60-, and 90-day post-discharge mortality. The true match rate for the "known dead" is 94 percent. |
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